A nurse is caring for a patient after a radical neck dissection.
What should be the nurse’s priority in the immediate postoperative period?
Ineffective airway clearance related to thick, copious secretions.
Impaired verbal communication related to the tracheostomy.
High risk for infection related to surgical incisions.
Malnourishment related to NPO Status and dysphagia.
The Correct Answer is A
Rationale for Choice A:
Ineffective airway clearance is the most immediate and life-threatening concern in the postoperative period following a radical neck dissection. This procedure involves extensive removal of lymph nodes and tissues in the neck, which can significantly disrupt normal respiratory function and airway patency. Here's a detailed explanation of the factors contributing to this risk:
Altered Respiratory Anatomy: The surgical resection of tissues and lymph nodes can directly impact the structure and function of the airway. This includes potential narrowing of the trachea, vocal cord dysfunction, and impaired laryngeal movement, all of which can hinder effective airflow.
Thick, Copious Secretions: The surgical trauma and manipulation of tissues often lead to increased production of thick, tenacious secretions in the respiratory tract. These secretions can obstruct the airway, making it difficult for the patient to clear them effectively.
Impaired Cough Reflex: The surgical dissection may disrupt the nerves involved in the cough reflex, which is a crucial mechanism for clearing secretions from the airway. This further impedes the patient's ability to maintain a patent airway.
Risk of Aspiration: Accumulation of secretions in the airway elevates the risk of aspiration, which can lead to pneumonia and other serious complications.
Potential for Edema: Postoperative swelling in the neck tissues can further compress the airway, exacerbating the risk of obstruction.
Nursing Interventions for Ineffective Airway Clearance:
Prompt recognition and management of ineffective airway clearance are essential to prevent respiratory compromise and ensure patient safety. Here are key nursing interventions that should be prioritized:
Frequent Assessment: Continuously monitor respiratory rate, effort, breath sounds, oxygen saturation, and level of consciousness for any signs of respiratory distress.
Positioning: Elevate the head of the bed to 30-45 degrees to promote lung expansion and facilitate drainage of secretions. Suctioning: Regularly suction the airway to remove secretions, using aseptic technique and proper suctioning pressure.
Deep Breathing and Coughing Exercises: Encourage and assist the patient with deep breathing and coughing exercises to mobilize secretions.
Humidification: Provide humidified oxygen or use a nebulizer to help thin secretions and make them easier to expectorate.
Chest Physiotherapy: Perform chest physiotherapy techniques, such as percussion and vibration, to loosen secretions and promote their removal.
Monitoring Fluid Balance: Maintain adequate hydration to help thin secretions, while closely monitoring fluid intake and output to prevent fluid overload.
Addressing Other Choices:
While the other choices may also be relevant concerns in the postoperative period, they do not pose the same immediate threat to life as ineffective airway clearance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Chronic pain can manifest in various behavioral and physical symptoms, including restlessness, pacing, grimacing, and other facial expressions of pain. These behaviors are often unconscious attempts to cope with or distract from the pain.
They may also reflect the emotional distress that often accompanies chronic pain. Patients may feel frustrated, anxious, or even depressed due to the persistent nature of their pain and its impact on their lives.
It's crucial for nurses to recognize these behavioral signs of pain, as patients may not always readily report their pain verbally. By observing these behaviors, nurses can assess the patient's pain level more accurately and provide appropriate interventions.
Choice B rationale:
Chronic pain is defined as pain that persists for longer than three months, often for much longer. It is not limited and short in duration.
This distinguishes it from acute pain, which is typically associated with an injury or illness and resolves within a few days or weeks.
Choice C rationale:
While some patients with chronic pain may have physical signs of tissue injury, this is not always the case. Chronic pain can also be caused by nerve damage, inflammation, or changes in the central nervous system.
In some cases, the underlying cause of chronic pain may be unknown.
Choice D rationale:
Although chronic pain may not always cause a significant change in vital signs, it can still be a very real and debilitating experience for patients.
Vital signs, such as heart rate, blood pressure, and respiratory rate, are often more sensitive to acute pain.
Nurses should not rely solely on vital signs to assess chronic pain. Instead, they should consider the patient's self-report of pain, behavioral cues, and other factors.
Correct Answer is C
Explanation
Choice A rationale:
Intractable pain is pain that is persistent and does not respond to usual pain management methods. While angina can be intractable in some cases, it does not typically manifest as pain in the arm and jaw. Moreover, the patient in this scenario has not yet undergone pain management efforts, so it's premature to classify the pain as intractable.
Choice B rationale:
Phantom pain is pain that is felt in a part of the body that has been amputated or is no longer there. The patient in this scenario has not experienced any amputations, so phantom pain is not a valid explanation for the arm and jaw pain.
Choice C rationale:
Referred pain is pain that is felt in a part of the body that is different from the source of the pain. This is the most likely explanation for the arm and jaw pain in this patient. The heart and the arm and jaw share nerve pathways, so pain signals from the heart can be misinterpreted by the brain as coming from these other areas. This is a common phenomenon in patients with angina.
Choice D rationale:
Cramping pain is a type of pain that is often described as a muscle tightening or squeezing sensation. It is not typically associated with angina. While angina can sometimes cause chest tightness, it's not characterized by cramping in the arm and jaw.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today